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Tobacco exposure results in various changes to the airways and lung parenchyma. Although emphysema represents the more common injury pattern, in some individuals, cigarette smoke injures alveolar epithelial cells and other lung cells, resulting in diffuse infiltrates and parenchymal fibrosis. Smoking can trigger interstitial injury patterns mediated via recruitment and inappropriate persistence of myeloid and other immune cells, including eosinophils. ⋯ Although respiratory bronchiolitis-interstitial lung disease, desquamative interstitial pneumonia, pulmonary Langerhans cell histiocytosis, and acute eosinophilic pneumonia have a well-established association with tobacco use, its role and impact on idiopathic pulmonary fibrosis, combined pulmonary fibrosis and emphysema, and connective tissue disease-related interstitial lung diseases is still ambiguous. Smoking-related interstitial fibrosis is a relatively newly appreciated entity with distinct histopathologic features but with unclear clinical ramifications. Increased implementation of lung cancer screening programs and utilization of CT scans in thoracic imaging have also resulted in increased identification of "incidental" or "subclinical" interstitial lung changes in smokers, the ensuing impact of which remains to be studied.
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Randomized controlled trials at times investigate findings suggested by observational studies. For example, the Towards a Revolution in COPD Health (TORCH) trial, which did not show a mortality reduction with inhaled corticosteroids (ICS) in COPD, was motivated by some observational studies that suggested considerable reductions in mortality with these drugs. Reasons for these discrepancies are unclear. ⋯ Observational studies are important to provide evidence from real-world data on medication effects. However, appropriate study design and analysis are essential to avoid biases and ensure randomized trials with greater chances of success. The observational studies suggesting potential beneficial effects of nonrespiratory drugs to treat COPD, such as statins and beta-blockers, will also need careful review before long and expensive randomized trials are conducted.
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Review Historical Article
On Doctors and Their Operas: A Critical (and Lyrical) Analysis of Medicine in Opera.
The goal of this research was to analyze the opera repertoire in terms of contents of physician roles. An additional goal was to pinpoint significant characters and passages that exemplify the changing role and perception of medicine in society over five centuries. A systematic search was performed. ⋯ Overall, the composer that appears with the highest interest in reporting disease is Giuseppe Verdi, with nine operas that include medical doctors. Finally, a trend can be observed regarding the evolving role of doctors, from mostly minor, buffal roles, either with magical or comical components in the 18th century, to a professional/technical physician more recently. Opera depicts a changing perception of the roles of doctors throughout history, with a blatant gender bias that still persists.
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Sepsis remains a significant cause of morbidity and mortality in the United States, leading to the implementation of the Severe Sepsis and Septic Shock Early Management Bundle (SEP-1). SEP-1 identifies patients with "severe sepsis" via clinical and laboratory criteria and mandates interventions, including lactate draws and antibiotics, within a specific time window. We sought to characterize the patients affected and to study the implications of SEP-1 on patient care and outcomes. ⋯ Delays in lactate measurement are associated with delayed antibiotics and increased mortality in patients with initial intermediate or elevated lactate levels. Systematic early lactate measurement for all patients with sepsis will lead to a significant increase in lactate draws that may prompt more rapid physician intervention for patients with abnormal initial values.
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Observational Study
Cystic Fibrosis Sputum Rheology Correlates With Both Acute and Longitudinal Changes in Lung Function.
Cystic fibrosis (CF) airway secretions are abnormal, contributing to decreased clearance and a cycle of infection and inflammation. CF sputum properties may predict disease progression. We hypothesized that sputum viscoelasticity and clearance abnormalities would inversely correlate with pulmonary function during exacerbation and that sputum properties would return to baseline after therapy. ⋯ Among these subjects with CF, there is a striking identity of the slope defining the relationship between ln G' or ln G'' and FEV1. There are dramatic increases in dynamic viscosity and elasticity during a pulmonary exacerbation with return to baseline at recovery. This suggests that sputum viscoelastic properties are tightly associated with lung function and disease status.